Evolving a Culture of Patient Safety Lessons from the Elimination of CLABS Allegheny General...

Evolving a Culture of Patient Safety

Lessons from the Elimination of CLABS

Allegheny General Hospital

Pittsburgh Regional Healthcare Initiative

The Key Message

• The data must not only be reportable, but actionable.

• You can come surprisingly close to eliminating hospital acquired infections with determination as opposed to resources.

• Hospital acquired infections are costing hospitals and society millions of dollars, illustrating the conspiracy of error and waste .

Who Are We?

• We are a 600 bed tertiary care teaching, hospital in Pittsburgh.

• 25,000 admissions with 6 ICU• The MICU and CCU are contiguous

units with 28 beds and about 1750 admissions each year.

• Cardiology and pulmonary fellows and categorical Internal Medicine Residents

What Did We Know (or think we knew) Before?

• Our results were average and average is ok.• CLABs are evitable. It is the price you pay for

sophisticated, complex care.• CLABs are benign and readily treated with

antibiotics.• CLABs are a common accompaniment of

complex care and covered in outlier payments.

Problems With Bench MarkingThe Difference Between Reporting and Actionable Data

01 Q3 01 Q4 02 Q1 02 Q2 02 Q3 02 Q4 03 Q1 03 Q20

1

2

3

4

5

6

7

8

9

10

CCU/MICU

NNIS

PRHI

Where Would You Want to Have a Central line Placed?

Unit 1

Teaching

Unit 2

Community

Unit 3

AMC

Rates 5/1000 line-days

5/1000 line-days

4/1000 line-days

# of infections

25 1 28

Line-days 500 lines X 10 days

50 lines X 4 days

360 lines X 19 days

Deaths 10 (40%) 0 (0%) 7 (25%)

Risk 1 in 20 1 in 50 1 in 13

What Does 5.1 infections/ 1000 line days Really Mean??

• 37 patients • 49 infections• 193 lines were employed (5.2 lines / patient)• 1753 admissions• 1063 patients had central access for more

than 12 hours• 1 out of 28 patients with a central line

became infected.

What Does 5.1 infections/ 1000 line days Really Mean??

• Blood Isolates Coagulase (-) Staph 17 (35%) Staph aureus 15 (30%) MRSA 10 (67%) Candida species 9 (19%) Gram negative rods 8 (16%)

What Did We Learn ?

• We were reporting only half of the actual CLABs.

• Central lines had a 3% chance of blood stream infection.

• Two-thirds of the infections involved virulent organisms . Twenty percent were MRSA.

• 19/37 patients died (51%).

What Not to Do?

• Don’t blame

• Don’t form another committee

• Make everybody responsible (not just the infection control officer !)

• Resist the temptation to meet / embrace the desire to act

• At the start, there are no right answers

What Did We Do?PPC

• Step 1: Make data actionable

• Step 2: Observe variations in work

• Step 3: Real time problem solving

• Step 4: Implement and test countermeasures

Toyota Production SystemRules in Use

• Activity (specified as to content sequence, timing, location, expected outcome)

• Connections (direct and unambiguous)• Pathways (predefined, simple and direct)• Improvement (highly specified under the

guidance of a mentor, at the level of the work, toward an ideal)

The Rules of TPS Applied to Healthcare

• Work (line placement and maintenance) should be highly specified such that variations/problems are immediately apparent.

• When problems (CLABs) are encountered, they should be solved to root cause in real time by the people doing the work.

• When a worker cannot solve a problem, they invoke the help chain to solve the problem.

Current Conditions

Chart review: 37 CLABS(July 2002-June 2003)

PRHI Central Line Data

Observations of Dressing Changes

Root Cause Analysis

Solve to root cause in real timethe origins of CLABS in

MICU / CCU

Counter Measures GeneratedBy the People That Do The Work

Eliminate CLABSIn MICU/CCUIn 90 days

Reassess ResultsGenerate AdditionalCounter Measures

Setting/Attending to Goals

• Goal de jour

• “Some is not a number..soon is not a time”

• Ambitious

Current Conditions




Root Cause Analysis


MICU / CCU




Variation in the Course of Work (Line Placement)

• No standard pre-procedure checklist

• Informed consent in 25% of procedures

• Eight different ways to “gown and glove”

• Six different ways to “prep and drape”

• Four different approaches to central veins

• Five different insertion kits

• 55% of procedures were documented

Variation in the Course of Work (Line Maintenance)

• No specified role• No standardized definitions of “site at

risk”• No standardized dressing kit• No standardized procedure for dressing

change• No standard record of line location and

duration.

Why is Disorder Condoned?

• Genetic variation

• The concept of individual care

• Physician autonomy

Genetic Variation: Highly Overrated

• Human genome: 27,000 genes

• Murine genome: 24,000 genes

• Drosophilia genome: 19,000 genes

It’s Quality not Quantity that Counts

Current Conditions




Root Cause Analysis


MICU / CCU




Real Time Problem SolvingJuly 2003

• R IJ infection (7/7)(MRSA)

• R fem infection (7/8)(E.Coli)

• Groshon catheter infection (7/9)

• Lines present on transfer (7/9)

• Re-wiring of line

• Catheter left in for > 96 hours

• Catheter choice

• Duration of line placement

Infection Cause

Root Cause Established Within 24 Hours

Understanding Problems Leads to Solutions

• Introducer linked and rewired

• Fem line in place > 96 hrs

• Patient transferred with line in place for 21 days

• Infected Groshon catheter

• Dysfunctional catheters should be replaced, not rewired

• Replace all femoral lines within 12 hours

• Replace line present on transfer

• Subclavian or PICC line preferred

Real Time Problem Solving Countermeasures

FY 2003 Traditional Approach

FY 2004 PPC Approach

ICU Admissions (n)ICU Admissions (n) 1753 1798PatientsPatients with CLABs (n)with CLABs (n) 37 6AgeAge ( (yearsyears)) 62 (24-80) 62 (50-74)Gender (male/female)Gender (male/female) 22/15 3/3 TotalTotal CLABSCLABS 49 6LineLine daysdays 4683 5052OverallOverall ratesrates(infections /1000 line days)(infections /1000 line days)

10.5 1.2

RatesRates reportedreported toto NNISNNIS(infections /1000 line days)(infections /1000 line days)

5.1 1.2

Deaths in patients with Deaths in patients with CLABsCLABs

19 (51%) 1 (16%)

ComparativeComparative ResultsResults

Risk of CLAB 1 in 28 1 in 185

Current Conditions




Root Cause Analysis


MICU / CCU




Additional Countermeasures

• Line Skills

• Lines for a long time

• Difficult access

• Education / Credentialing

• BioPatch dressings

• SonoSite ultrasound

• Micropuncture kits

• Vascular access team

• Antibiotic locks

Real Time Problem Solving Countermeasures

Summary

• CLABs are a common, morbid and mortal complication of ICU care

• Femoral lines contribute significantly to the problem and should be considered in the NNIS definition

• CLABs can be eliminated (nearly).

Drivers of Change

• Moral: it’s the right thing to do

• Scientific: It works

• Practical: It can be done in your hospital, not just a research setting

•Economics: What’s the impact on the hospital’s and system’s bottom line?

The Conspiracy of Error and Waste

• What is the cost of a CLAB in human and financial terms?

• What does society pay for healthcare associated infections (HAI)?

• Do hospitals and physicians make money on HAIs ?

Case 1:

• 37 year old video game programmer, father of 4, admitted with acute pancreatitis secondary to hypertriglyceridemia.

• Day 3: developed hypotension, and respiratory failure• Day 6 : fever and blood cultures positive for MRSA

secondary to a femoral vein catheter in place for 4 days.

• Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy

• Day 86: Discharged to nursing home• Highmark Select Blue

6 86

CLAB

Day 1

2/07/02Transfer 5/04/022/12/02M. S.

T o ta l C o s t o fP a tien t S tay2 4 1 ,8 4 3 .8 2

T o ta l C o s t a f te rC L AB

2 2 9 ,3 8 1 .0 8

T o ta l C o s t b ef o r eC L AB

1 2 ,4 6 2 .7 4

T o ta l Attr ib u tab leC o s t

1 7 0 ,5 6 5 .1 2

N o t R ela ted toC L AB

5 8 ,8 1 5 .9 6

M I C U S er v ic e1 0 6 ,7 3 7 .5 6

P r im ar y to C L AB5 2 ,9 1 4 .0 9

S ec o n d ar y to C L AB1 0 ,9 1 3 .4 7

T o ta l Attr ib u tab leC o s t0 .0 0


1 2 ,4 6 2 .7 4

T o tal C o s t A ttrib u tab le toIn fe c tio n

1 7 0 ,5 6 5 .1 27 0 .5 3 % o f T o tal

T o ta l Attr ib u tab le C o s tBef o r e C L AB

0 .0 0

T o ta l Attr ib u tab le C o s tAf ter C L AB1 7 0 ,5 6 5 .1 2

P r im ar y to C L AB0 .0 0

S ec o n d ar y to C L AB0 .0 0

Case 3

Charges CostPrimary and Secondary Total Before CLAB 96.00 16.93Primary and Secondary Total After CLAB 36,075.00 5,856.10Total Variable Cost 36,171.00 5,873.03

MICU Service After CLAB 91,644.00 35,136.14Floor Service After CLAB 0.00 0.00Total Fixed Cost 91,644.00 35,136.14

Total Variable Cost 36,171.00 5,873.03Total Fixed Cost 91,644.00 35,136.14Total Cost Attributable to Infection 127,815.00 41,009.17

Total Cost of Entire Stay 359,315.00 117,626.21

Attributable Cost as a Percent of Total 34.86%

Charges and Costs Attributable to CLAB

The Impact of CLABs on Gross MarginDRG 204/2721

(n=3)

DRG 191

(n=3)

DRG 483

(n=2)

Case 1

Acute pancreatitis

Pancreatitis w cc

Pancreatitis w trach

Revenue ($) 5,907 99,214 125,576 200,031

Expense 5,788 58,905 98,094 241,844

Gross Margin

119 40,309 27,482 -41,813

Costs attributable to CLAB

170,565

LOS 4 38 41 86

Case 3

• 49 year old obese female was admitted for elective surgical gastroplasty.

• She developed respiratory distress post operatively and was intubated for respiratory failure.

• On day 22, blood cultures were positive for Staph epidermidis, enterococcus fecaelis, and Candida.

• The right femoral line tip grew all three organisms. The line was in place for 16 days.

• On hospital day 48, she was transferred to a SNF.

• Medicare/ Three Rivers

Day 1

1/20/03

22

CLAB 2/10/03

48

Transfer 3/08/03

T o ta l C o s t o fP a tien t S tay1 1 7 ,6 2 6 .2 1

T o ta l C o s t a f te rC L AB

6 4 ,5 7 8 .5 9

T o ta l C o s t b ef o r eC L AB

5 3 ,0 4 7 .6 4


4 0 ,9 9 2 .2 4


2 3 ,5 8 6 .3 5

C C U S er v ic e3 5 ,1 3 6 .1 4

P r im ar y to C L AB5 ,3 7 1 .3 4

S ec o n d ar y to C L AB4 8 4 .7 6


1 6 .9 3


5 3 ,0 3 0 .7 1

T o tal C o s t A ttrib u tab le toI n fe c tio n

4 1 ,0 0 9 .1 73 4 .8 6 % o f T o tal

T o ta l Attr ib u tab le C o s tBef o r e C L AB

1 6 .9 3

T o ta l Attr ib u tab le C o s tAf te r C L AB4 0 ,9 9 2 .2 4

P r im ar y to C L AB1 6 .9 3

S ec o n d ar y to C L AB0 .0 0

Case 1

Charges CostPrimary and Secondary Total Before CLAB 0.00 0.00Primary and Secondary Total After CLAB 290,357.00 63,827.56Total Variable Cost 290,357.00 63,827.56

MICU Service After CLAB (82 days) 266,518.00 106,737.56Floor Service After CLAB 0.00 0.00Total Fixed Cost 266,518.00 106,737.56

Total Variable Cost 290,357.00 63,827.56Total Fixed Cost 266,518.00 106,737.56Total Cost Attributable to CLAB 556,875.00 170,565.12

Total Cost of Entire Stay 828,847.00 241,843.82

Attributable Cost as Percent of Total 70.53%

Charges and Costs Attributable to CLAB

The Impact of CLABs on Gross Margin

DRG 288

(n=10)

DRG 483

(n=3)

Case 3

Procedures for obesity

Trach w obesity surgery

Revenue 22,023 153,566 101,521

Expense 12,100 148,969 117,626

Gross Margin 9,923 6,597 -16,105

Costs attributable to CLAB

41,009

LOS 6 51 47

CLABS Scorecard

Optimal

Care

Less than optimal care

Less than optimal + CLAB

Patient + - - ---Payor + -- ---Provider

Hospital+ ++ ---

Provider

Physician+ ++ +++

CLABs*

(n=72)

VAP*

(n=33)

MRSA**

(n=188)

( per patient)

Revenue ($) 68,183 95,272 26,112

Expenses 82,183 112,459 69,343

Gross Margin -14,572 -17,187 -43,231

LOS 35 51 19

Mortality 25% 30% 16%

The Human and Economic Costs of Nosocomial Infections

* Defined by Infection Control ** no routine surveillance

AGH Losses Associated with Nosocomial Infections

[$8,769,403](-16,147,813)(-$9,743,783)Loss associated with nosocomial infections

[$7,314,685](-$12,130,489)(-$8,127,428)MRSA

(n=188)

[$510,453](-$2,268,684) (-$567,171)VAP

(n=33)

[$944,265](-$1,748,640) (-$1,049,184)CLAB

(n=72)

Saving

(90% Reduction)

Projected Based Upon Underreporting

ActualGross Margins

(FY 04)

What Could You Do With $10 million?

• Hire 166 nurses or ICPs• Hire 200 respiratory techs• Hire 220 more interns• Give all 3,500 employees a $2,857 raise• Buy 2.5 million BioPatch dressings• Insure one thousand uninsured Americans• Treat 8,000 Haitians with HIV

Progress: It Can Be Infectious

• Initiatives now across all units

• VAPs reduced by 70%

• CLABs reduced by 40%

• MRSA surveillance (96%)

8% of admissions

2% transmission rate

• Real Time Mortality review

Conclusions

• The human and financial costs of CLABs are daunting.

• These costs do not include physician costs or costs of skilled nursing care. Thus, the magnitude remains understated.

• The costs of CLABs are not recovered in outlier payments.

• The elimination of nosocomial infections, in general, and CLABs, in particular is multi-million dollar proposition for the healthcare industry.

July 2002 Jluy 2003 July 2004 Apr 20050

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Central Line Associated Blood Stream Infections

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7080

90100

Checklist Prep Dr

BeforeAfter

Sources of Variation

• Observations and standardization of dressing changes.

SC: 5 minutes

IJ: 5 minutes

Fem: 15 minutes• Standardize dressing change kits• Document current condition of site daily• Assist in understanding PICC line use PRHI

Evolving a Culture of Patient Safety Lessons from the Elimination of CLABS Allegheny General...

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